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Medical Director

Job typeFull Time
CountryUnited States
Position scope:

Primarily regional with national level case work for Cigna Healthcare (CHC) -- Cigna, & CareAllies.

Market and Regional level case work for Cigna Medicare.

Summary description of position: A Medical Principal performs medical review and case management activities. The physician provides clinical insight to the organization through peer review, benefit review, consultation, and service to internal and external customers. He/she will serve as a clinical educator and consultant to utilization management, case management, network, contracting, pharmacy, and service operations (claims). This is an entry to mid-level position for a physician interested in a career in health care administration. The Medical Director role is a Medical Principal who also manages 2 or more direct reports.

Major responsibilities and required results:
  • Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution, using benefit plan information, applicable federal and state regulations, clinical guidelines, and best practice principles.
  • Works to achieve quality outcomes for customers/members with a focus on service and cost
  • Improves clinical outcomes through daily interactions with health care professionals using active listening, education, and excellent communication and negotiation skills.
  • Balances customer/member needs with business needs while serving as a customer/member advocate at all times.
  • Participates in all levels of the Appeal process as appropriate and allowed by applicable regulatory agencies and accreditation organizations
  • Participates in coverage guideline development, development and maintenance of medical management projects, initiatives and committees.
  • Participates in quality processes such as audits, inter-rater reliability clinical reviews, and quality projects
  • Serves as a mentor or coach to other Medical Directors and other colleagues in quality and performance improvement processes.
  • Improves health care professional relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships.
  • Addresses customer service issues with mentoring and support from leadership staff.
  • Investigates and responds to client and/or regulatory questions to assist in resolving issues or clarifying questions with mentoring and support from leadership staff.
  • Achieves internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.
  • Provides clinical insight and management support to other functional areas and matrix partners as needed or directed.

Cigna Medicare:
  • Directs and implements medical policy and ensures the quality of medical care provided to customers/members for single-market health plans
  • Responsible for chairing appropriate health services committees and providing leadership for pharmacy and health services utilization management projects for single-market health plans

Minimum Requirements:
  • Current unrestricted medical license in a US state or territory
  • Current board certification (lifetime certification or certification maintained by MOC or other applicable program) in an ABMS or AOA recognized specialty
  • Exhibits ethical and professional behavior.
  • Minimum of 5 years of clinical practice experience and/or direct patient care beyond residency
  • Computer Competency: Word processing, Spreadsheet, Email, PowerPoint and Personal Information Management programs are used extensively and competency in all must be possessed or rapidly acquired.
  • Must not be excluded from participation in any federal health care program**
  • Must not be included in CMS' Preclusion List**

Minimum Requirements - Cigna West Medical Principals or Medical Directors hired prior to July 2009:
  • Current unrestricted medical license in a US State or territory
  • Current board-certification in an ABMS or AOA recognized specialty (grandfathered by the board or maintained by the MOC program)
  • Preference for previous clinical practice experience and/or direct patient care beyond residency.

Minimum Requirements - Cigna Medicare Medical Principals or Medical Directors hired prior to January 2014**
  • A current, unrestricted license to practice within the scope of his or her profession in a State, Territory, Commonwealth of the United States or the District of Columbia.
  • Preference for previous clinical practice experience and/or direct patient care beyond residency.

**Perform responsibilities specific to Medicare

Preferred Skill Sets:
  • Experience in medical management, utilization review and case management in a managed care setting.
  • Knowledge of managed care products and strategies.
  • Ability to work within changing business environment and balance patient advocacy with business needs.
  • Experience with managing multiple projects in a fast-paced matrix environment.
  • Demonstrated ability to educate colleagues and staff members.
  • Successful experience and comfort with change management.
  • Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem solving skills.
  • Successful ability to assess complex issues, to determine and implement solutions, and resolve problems.
  • Success in creating and maintaining cooperative, successful relations with diverse internal and external stakeholders.
  • Demonstrated sensitivity to culturally diverse situations, participants, and customers/members.
  • Service marketing, sales, and business acumen experience a plus.
  • Fluency in Spanish (Cigna Medicare) or other languages

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
Employer828 Newquest LLC